CT-guided core needle biopsy of pulmonary lesions: a better tool for radiologist and clinician

CT-guided core needle biopsy of pulmonary lesions: a better tool for radiologist and clinician Poster No.: C-2476 Congress: ECR 2018 Type: Educational Exhibit Authors: A. Kosolapov, I. Blokhin, P. Gelezhe; Moscow/RU Keywords: Pathology, Neoplasia, Cancer, Laboratory tests, Complications, Biopsy, CT, Thorax, Oncology, Interventional non-vascular DOI: 10.1594/ecr2018/C-2476 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. www.myesr.org Page 1 of 13

Learning objectives To characterize CT-guided core needle biopsy (CNB) in the evaluation of pulmonary lesions To define the prospects for its development in the light of targeted therapy advancement Page 2 of 13

Background Lung cancer mortality in 2012 estimates to be 1.8 million cases (12.9%). Pulmonary adenocarcinoma is the most common (~40%) tumor type [1]. Treatment tactics is constantly reviewed, tested and updated. Genomic-based treatment has proved to be the most effective. Targeted therapy can improve the outcome [2,3]. This requires tissue sampling and pathological testing. Pulmonary lesions are notoriously known for being hard to sample. It is due to fewer possible approaches and higher complication risk. CNB is the gold standard for sampling peripheral pulmonary lesions [3]. Page 3 of 13

Findings and procedure details CT-guided core needle biopsy is usually performed in the "step-by-step" mode under local anesthesia. The procedure is possible on any modern scanner. We use 16-, 64- and 256-detector models. Patient positioning depends on lesion localization. In our institution, we use the single-pass technique with 20-22G needles. The technique was chosen after careful evaluation of "safety-effectivenes" balance for various procedures. Biopsy-performing personnel reviews thoracic CT scans and discusses procedure safety and possible complications. The key point are lesion localisation, bone-free "window" and "track" devoid of bronchi and major vessels. CNB should be avoided in patients on antiplatelet therapy. It should be cancelled for at least 1 week before biopsy. CNB is contraindicated in panlobular and bullous emphysema due to high risk of massive pneumothorax. Technique The procedures were performed under local anesthesia in aseptic conditions. We used standard vendor-provided CT-guided biopsy protocol: 30mAs, 120kV, 3-mm slice thickness in soft tissue window without additional reconstructions for reduce procedure duration. Patient position is based on the lesion's localization; preferable parameters include the shortest "skin-to-lesion" distance with "needle-to-skin" angle of 90 degrees. A chest CT during free breathing brings us up-to-date on lesion size and aids "track" selection. After local anesthesia, a second scan is perfomed. Typically, directions of the needle for anesthesia and biopsy coincide. When the specialist introduces a biopsy needle, he navigates it step-by-step (i.e., slice-by-slice) until he reaches the nodule. Nodule size affects needle movement increment. After creating vacuum with the syringe, one obtains histologic material with few intensive "picks". Immediate and 2-hour control scan will reveal procedure-induced complications. Results Bleeding and pneumothorax are two common operator-dependent complications. Out of 97 biopsies, 42 samples turned out to be lung adenocarcinomas. Genetic evaluation was performed in 27 cases. In 2 cases post-procedural pneumothorax required hospitalization. In 11 cases pneumothorax was managed conservatively. One case of minimal hemoptysis was reported. Core needle biopsy with 20/22G needles was successfully implemented in our practice. It is well-received by oncologists and pathologists. Page 4 of 13

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Images for this section: Fig. 1 X-ray department, 35, ul. Schepkina, Moscow, 129090, European Medical Center Moscow/RU Page 6 of 13

Fig. 4 X-ray department, 35, ul. Schepkina, Moscow, 129090, European Medical Center Moscow/RU Page 7 of 13

Fig. 5 X-ray department, 35, ul. Schepkina, Moscow, 129090, European Medical Center Moscow/RU Page 8 of 13

Fig. 6 X-ray department, 35, ul. Schepkina, Moscow, 129090, European Medical Center Moscow/RU Page 9 of 13

Fig. 2 X-ray department, 35, ul. Schepkina, Moscow, 129090, European Medical Center Moscow/RU Page 10 of 13

Fig. 3 X-ray department, 35, ul. Schepkina, Moscow, 129090, European Medical Center Moscow/RU Page 11 of 13

Conclusion Development of targeted therapy calls for tissue sampling optimization. CT-guided core needle biopsy strikes a good balance between effectiveness and availability. A radiologist familiar with this procedure can complement treatment planning. Page 12 of 13

References 1. 2. 3. Ferlay J, Soerjomataram I, Ervik M, Dikshit R, Eser S, Mathers C, Rebelo M, Parkin DM, Forman D, Bray, F. GLOBOCAN 2012 v1.0, Cancer Incidence and Mortality Worldwide: IARC CancerBase No. 11 [Internet]. Cox VL, Bhosale P, Varadhachary GR, Wagner-Bartak N, Glitza IC, Gold KA, Atkins JT, Soliman PT, Hong DS, Qayyum A. Cancer Genomics and Important Oncologic Mutations: A Contemporary Guide for Body Imagers. Radiology. 2017 May;283(2):314-340. doi: 10.1148/radiol.2017152224. Neema Jamshidi, MD, PhD, Danshan Huang, MD, PhD, Fereidoun G. Abtin, MD, Christopher T. Loh, MD, Stephen T. Kee, MD, Robert D. Suh, MD, Shota Yamamoto, MD, Kingshuk Das, MD, Sarah Dry, MD, Scott Binder, MD, Dieter R. Enzmann, MD, Michael D. Kuo, MD Genomic Adequacy from Solid Tumor Core Needle Biopsies of ex Vivo Tissue and in Vivo Lung Masses: Prospective Study. Radiology, Volume 282, Issue 3, March 2017. Page 13 of 13